| NPI | 1366795379 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 208D00000X General Practice (Licence: PR 18594) |
| Additional Taxonomies | 208D00000X General Practice (Licence: NE 30927) |
| Enumeration Date | 2012-10-16 |
| Last Update Date | 2018-08-10 |